Popup after charity – Tpllife

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First Name(Required)

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Last Name(Required)

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YYYY/MM/DD(Required)

YYYY slash MM slash DD

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Age(Required)

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Gender(Required)

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Mobile Number(Required)

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Email(Required)

Who do you want to be
Covered Under the SHIELD?

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Who do you want to be covered under the shield?(Required)

Myself

Me & My Family

Others

Plans(Required)

PKR
60,000

Annual Coverage

PKR
100,000

Annual Coverage

PKR
200,000

Annual Coverage

PKR
350,000

Annual Coverage

PKR
500,000

Annual Coverage

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Click on the desired COVERAGE you need

60,000

100,000

200,000

350,000

500,000

Salamati Plan

Annual Plan Coverage

PKR 350,000

For each family member

Emergency Evacuation

Accidental Emergency Expense

Daily Room and Board

Maternity Coverage

Monthly Premium

PKR 30,000

For 4 family member
The insurance amount for each family member is PKR 6,256 per month

Aram Plan

Annual Plan Coverage

PKR 60,000

For each family member

Emergency Evacuation

Accidental Emergency Expense

Daily Room and Board

Maternity Coverage

Monthly Premium

PKR 30,000

For 4 family member
The insurance amount for each family member is PKR 6,256 per month

Aafiyat Plan

Annual Plan Coverage

PKR 100,000

For each family member

Emergency Evacuation

Accidental Emergency Expense

Daily Room and Board

Maternity Coverage

Monthly Premium

PKR 30,000

For 4 family member
The insurance amount for each family member is PKR 6,256 per month

Rahat Plan

Annual Plan Coverage

PKR 200,000

For each family member

Emergency Evacuation

Accidental Emergency Expense

Daily Room and Board

Maternity Coverage

Monthly Premium

PKR 30,000

For 4 family member
The insurance amount for each family member is PKR 6,256 per month

Rahat Plan

Tahaffuz Plan Coverage

PKR 500,000

For each family member

Emergency Evacuation

Accidental Emergency Expense

Daily Room and Board

Maternity Coverage

Monthly Premium

PKR 30,000

For 4 family member
The insurance amount for each family member is PKR 6,256 per month

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Maternity Coverage(Required)

Remove Maternity Coverage

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Maternity Coverage for family(Required)

Maternity Coverage

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Select Hospital Checkbox(Required)

CHILDLIFE FOUNDATION

ZINDAGI TRUST

SAYLANI

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Select Inshu(Required)

CHILDLIFE FOUNDATION

ZINDAGI TRUST

SAYLANI

The Hunar Foundation

Indus Hospital

JDC

Hussaini Foundation

Patients Aid Foundation

Panah

I don’t want to contribute

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I don’t want to contribute(Required)

I don’t want to contribute

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Gender male

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Gender female

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Gender x

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Add Wife

Please enter a number from 0 to 4.

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Add Husdand

Please enter a number from 0 to 4.

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Add son

Please enter a number from 0 to 6.

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Add daughter

Please enter a number from 0 to 6.

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No of Members

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Wife’s Birthday

YYYY slash MM slash DD

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2nd Wife’s Birthday

YYYY slash MM slash DD

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3rd Wife’s Birthday

YYYY slash MM slash DD

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4rth Wife’s Birthday

YYYY slash MM slash DD

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Son’s Birthday

YYYY slash MM slash DD

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2nd Son’s Birthday

YYYY slash MM slash DD

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3rd Son’s Birthday

YYYY slash MM slash DD

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4rth Son’s Birthday

YYYY slash MM slash DD

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5th Son’s Birthday

YYYY slash MM slash DD

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6th Son’s Birthday

YYYY slash MM slash DD

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Daughter's Birthday

YYYY slash MM slash DD

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2nd Daughter's Birthday

YYYY slash MM slash DD

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3rd Daughter's Birthday

YYYY slash MM slash DD

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4rth Daughter's Birthday

YYYY slash MM slash DD

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5th Daughter's Birthday

YYYY slash MM slash DD

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6th Daughter's Birthday

YYYY slash MM slash DD

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Selected Products

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Products Number

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Annual Plan Coverage

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Maternity Aaram

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Maternity Salamati

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Maternity Aafiyat

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Maternity Rahat

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Maternity Tahafuz

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Aram without Mat

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Aram with Mat

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Salamati without Mat

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Salamati with Mat

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Aafiyat without Mat

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Aafiyat with Mat

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Rahat without Mat

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Rahat with Mat

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Tahafuz without Mat

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Tahafuz with Mat

01 Of 07

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Are you presently in good health?

Yes

No

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Are you presently taking any medication, therapy/treatment?

Yes

No

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Have you ever suffered from any physical or mental illness/ medical ailment (Pre-existing condition) or any deformities?

Yes

No

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Do you smoke or indulge in Alcohol?

Yes

No

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Have you ever in the past or currently are involved in any legal, religious political activities or are you engaged or ever had any involvement in any civil or criminal litigation or police case?

Yes

No

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Does your job involve any hazardous activity(ies)?

Yes

No

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Does your job involve any hazardous activity(ies)?

Yes

No

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Are you a domestic/foreign “Politically Exposed Person” (PEP) or a family member/close associate of a domestic/foreign “Politically Exposed Person” (PEP)?

Yes

No

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Are you pregnant?

Yes

No

Congratulations

Words cannot express how grateful we are for your willingness to volunteer.

Thank you!

You now have the option to swiftly navigate to the Health Declaration
form or continue onward with Inshu Charity.

Great Job!

Words cannot express how grateful we are for your
willingness to volunteer